🩸 Chapter 111: Febrile Neutropenia

Definition (ANC <500, fever >38.3°C) · High-risk vs low-risk · Empiric antibiotics (antipseudomonal beta-lactam ± vancomycin) · De-escalation vs escalation · Antifungal therapy · Prophylaxis (PJP, fungal, HSV) · Colony-stimulating factors · Duration until ANC >500

🔍 Core Concepts: Febrile Neutropenia

📌 Definition
Fever >38.3°C or >38.0°C sustained for 1h. Neutropenia: ANC <500 cells/mm³ (or expected to drop <500 in 48h). Profound neutropenia: ANC <100.
⚠️ High-Risk Features
Profound neutropenia (>7 days), haemodynamic instability, pneumonia, mucositis, abdominal pain, renal/hepatic insufficiency, catheter infection, comorbidities. Admit, IV antibiotics.
💊 Empiric Antibiotics (High-risk)
Antipseudomonal beta-lactam: cefepime, meropenem, or piperacillin-tazobactam. Add vancomycin if: hypotension, pneumonia, catheter infection, MRSA colonisation, severe mucositis.
📉 De-escalation vs Escalation
De-escalation: broad initial (carbapenem) then narrow based on cultures. Escalation: narrower initial (cefepime) then broaden if deterioration or resistant organism.
🦠 Antifungal Therapy
Consider after 4-7 days of persistent fever if neutropenia expected >7 days, or complicated presentation (shock, MODS). Options: caspofungin, liposomal amphotericin, voriconazole.
🛡️ Prophylaxis
PJP: TMP-SMX. Fungal: fluconazole/posaconazole (high-risk). HSV: acyclovir (seropositive). Colony-stimulating factors if anticipated >20% febrile neutropenia risk.

🩺 Stepwise Approach: Febrile Neutropenia

1
Risk assessment
ANC, expected duration of neutropenia. High-risk: profound neutropenia (>7 days), haemodynamic instability, pneumonia, mucositis, abdominal pain, renal/hepatic failure, catheter infection, uncontrolled comorbidities.
2
Obtain cultures & imaging
Blood cultures (peripheral and from each CVC lumen). Urine, sputum, stool if clinically indicated. Chest X-ray if respiratory symptoms.
3
Start empiric IV antibiotics (high-risk)
Cefepime (50 mg/kg/dose q8h), meropenem (20-40 mg/kg/dose q8h), or piperacillin-tazobactam (80-100 mg/kg/dose q6h). Add vancomycin if specific indications (hypotension, pneumonia, catheter infection, MRSA colonisation, severe mucositis).
4
Modify based on cultures/resistance
De-escalate if organism identified and stable. Escalate (e.g., to carbapenem, add colistin) if MDR pathogens suspected or deterioration.
5
Consider antifungal therapy
If fever persists >4-7 days with broad-spectrum antibiotics, neutropenia expected >7 days, or complicated presentation (shock, MODS). Use caspofungin, liposomal amphotericin, or voriconazole.
6
Continue until recovery
Continue antibiotics until ANC >500 and afebrile for 24-48h. For documented infection, treat full course.